Ulcers and Skin Damages (TI P2)

Question 1

Pressure Ulcers

Answer 1

also called pressure injury
localized injury to skin and/or underlying tissue

Question 2

What do pressure ulcers result from?

Answer 2

prolonged pressure or pressure in combination with shearing forces
can be related to medical or other devices

Question 3

Where are pressure ulcers most commonly found?

Answer 3

over bony prominences, sacrum, heels

Question 4

Describe the pathophysiology of pressure ulcer development

Answer 4

pressure over a prolonged period of time will stop capillary flow to the tissues, which will deprive tissues of oxygen and nutrients, and will eventually lead to cell death or tissue necrosis

Question 5

What are influencing factors to pressure ulcers?

Answer 5

pressure intensity
pressure duration
tissue tolerance factors
shearing forces
moisture

Question 6

What could affect the ability of a tissue to tolerate the pressure (tissue tolerance factors)?

Answer 6

nutrition
perfusion
co-morbidities
condition of soft tissue

Question 7

What are risk factors to pressure ulcers?

Answer 7

advanced age
anemia
diabetes
elevated body temperature
friction
immobility
impaired circulation
incontinence
low diastolic BP
mental deterioration
neurological disorders
obesity
pain
prolonged surgery
vascular disease

Question 8

What are clinical manifestations of pressure ulcers?

Answer 8

depends of extent of tissue
staged/categorized based on visible or palpable tissue in the ulcer bed
presence of slough or eschar may prevent staging until it is removed

Question 9

Suspected Deep Tissue Injury

Answer 9

purple or maroon localized area of discolored intact skin or blood-filled blister
indicates damage of underlying soft tissue from pressure and/or shear
may be preceded by tissue that is painful, firm, mushy, boggy

Question 10

When assessing patients with darker skin, you should…

Answer 10

look for areas of the skin that are darker than the surrounding skin; may appear purple, brown, or blue

Question 11

When assessing skin temperature with your hand, the ulceration should feel _____ initially, then become _____ with time

Answer 11

warm; cooler

Question 12

Boggy or edematous tissue may indicate…

Answer 12

stage 1 pressure ulcer

Question 13

Stage 1 Pressure Ulcer

Answer 13

intact skin, non-blanchable redness of localized area
common over bony prominence
may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue

Question 14

Stage 2 Pressure Ulcer

Answer 14

partial-thickness loss of dermis
shallow open ulcer with red/pink wound bed
may also present as an intact or ruptured serum-filled blister

Question 15

Stage 3 Pressure Ulcer

Answer 15

full-thickness loss
subcutaneous tissue may be visible
presents as deep crater (depth varies on location)

Question 16

Stage 4 Pressure Ulcer

Answer 16

full-thickness loss, extends to bone, muscle, or supporting structures
bone, tendon, muscle may be visible or palpable
slough or eschar may be present
undermining or tunneling may occur

Question 17

Unstageable Ulcer

Answer 17

full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed

Question 18

In the case of an unstageable ulcer, should stable, dry eschar on heels be removed?

Answer 18

No

Question 19

What is the #1 complication we want to prevent with pressure ulcers?

Answer 19

infection

Question 20

What are signs of infection with pressure ulcers?

Answer 20

leukocytosis (high WBC)
fever
increased ulcer size, odor, or drainage
necrotic tissue
indurated, warm, painful

Question 21

Untreated ulcers may lead to…

Answer 21

cellulitis, with spread of inflammation/infection to subcutaneous tissue, connective tissue, bone (osteomyelitis), can lead to sepsis and death

Question 22

Most common complication of ulcers is…

Answer 22

recurrence of tissue breakdown/repeat pressure ulcers

Question 23

Nursing Assessment + Management

Answer 23

assess skin of EVERY patient on admission and every shift
assess ALL patients for risk for skin breakdown every 12 hours
stage 3 and 4 pressure injuries acquired after admission- NEVER want to happen

Question 24

What are some strategies to help prevent pressure ulcers?

Answer 24

redistribute pressure
keep skin dry
reposition- position patient at 30 degrees lateral position
turning schedule
nutrition and fluid intake

Question 25

Care Planning

Answer 25

prevent deterioration
reduce factors that contribute to ulcers and skin breakdown
prevent infection
promote healing
prevent recurrence

Question 26

What should you do if your patient develops a pressure injury?

Answer 26

document size, location, exudate, infection, pain, and tissue appearance
some facilities may require a photo

Question 27

What is important to discuss during patient and family teaching?

Answer 27

teach prevent techniques including early signs of ski breakdown and tissue integrity
continued nutritional support
wound care at home
TURNING SCHEDULE

Question 28

Lower Extremity Ulcers

Answer 28

related to changes in blood flow to lower extremities due to chronic disease processes

Question 29

Arterial ulcers can be caused by

Answer 29

PAD, causes problems with blood flow in arteries, becoming narrow or blocked, usually caused by atherosclerosis
ulcers caused by schema and nutrition deprivation as a result of decreased circulation

Question 30

How will the skin look with arterial ulcers?

Answer 30

skin will be shiny, thin, dry, with loss of hair on ankles, feet

Question 31

Who is at an increased risk for arterial ulcers?

Answer 31

those with atherosclerosis, PVD, diabetes, smoking, hypertension, advanced age, obesity, and cardiovascular disease

Question 32

What do arterial ulcers look like? Where can they be found?

Answer 32

EVEN WOUND MARGINS, punched-out appearance, pale, deep wound bed
extremely painful, minimal exudate

can be found between toes or on tips of toes, on phalangeal head, lateral malleolus, or areas with rubbing footwear

Question 33

Who is at an increased risk for venous leg ulcers?

Answer 33

those with obesity, DVT, CHF, pregnancy, incompetent valves, muscle weakness, decreased activity, advanced age, family history

Question 34

Venous insufficiency occurs when

Answer 34

blood cannot flow upward from veins in legs

Question 35

Chronic venous insufficiency occurs when

Answer 35

valves are damaged, allowing blood to leak backwards, resulting inn venous stasis

Question 36

What do venous leg ulcers look like? Where are they found?

Answer 36

IRREGULAR WOUND MARGINS, superficial, ruddy granular tissue; surrounding skin may be red, scaly, weepy, thin
painless to moderately painful

found in lower legs

Question 37

Diabetic ulcers are caused by

Answer 37

peripheral neuropathy
fissures in skin
decreased ability to fight infection
diabetic food deformities caused by damage to ligaments and destruction of bone

Question 38

Diabetic ulcers can easily turn into

Answer 38

cellulitis or osteomyelitis

Question 39

What do diabetic ulcers look like? Where are they located?

Answer 39

painless, EVEN wound margins, rounded or oblong shape with surrounding callous

located on plantar aspect of foot, over metatarsal heads, under heels, and on toes (bony prominences)